Association of Spinal Cord Atrophy and Brain Paramagnetic Rim Lesions With Progression Independent of Relapse Activity in People With MS.

Progression independent of relapse activity (PIRA) is a crucial determinant of overall disability accumulation in multiple sclerosis (MS). Accelerated brain atrophy has been shown in patients experiencing PIRA. In this study, we assessed the relation between PIRA and neurodegenerative processes reflected by (1) longitudinal spinal cord atrophy and (2) brain paramagnetic rim lesions (PRLs). Besides, the same relationship was investigated in progressive MS (PMS). Last, we explored the value of cross-sectional brain and spinal cord volumetric measurements in predicting PIRA. From an ongoing multicentric cohort study, we selected patients with MS with (1) availability of a susceptibility-based MRI scan and (2) regular clinical and conventional MRI follow-up in the 4 years before the susceptibility-based MRI. Comparisons in spinal cord atrophy rates (explored with linear mixed-effect models) and PRL count (explored with negative binomial regression models) were performed between: (1) relapsing-remitting (RRMS) and PMS phenotypes and (2) patients experiencing PIRA and patients without confirmed disability accumulation (CDA) during follow-up (both considering the entire cohort and the subgroup of patients with RRMS). Associations between baseline MRI volumetric measurements and time to PIRA were explored with multivariable Cox regression analyses. In total, 445 patients with MS (64.9% female; mean [SD] age at baseline 45.0 [11.4] years; 11.2% with PMS) were enrolled. Compared with patients with RRMS, those with PMS had accelerated cervical cord atrophy (mean difference in annual percentage volume change [MD-APC] -1.41; p = 0.004) and higher PRL load (incidence rate ratio [IRR] 1.93; p = 0.005). Increased spinal cord atrophy (MD-APC -1.39; p = 0.0008) and PRL burden (IRR 1.95; p = 0.0008) were measured in patients with PIRA compared with patients without CDA; such differences were also confirmed when restricting the analysis to patients with RRMS. Baseline volumetric measurements of the cervical cord, whole brain, and cerebral cortex significantly predicted time to PIRA (all p ≤ 0.002). Our results show that PIRA is associated with both increased spinal cord atrophy and PRL burden, and this association is evident also in patients with RRMS. These findings further point to the need to develop targeted treatment strategies for PIRA to prevent irreversible neuroaxonal loss and optimize long-term outcomes of patients with MS

The bovine pericardial patch in breast reconstruction: a case report

In the last years there has been a growing demand of plastic surgery for soft tissue reconstruction. In response to this, many biological and synthetic devices have been produced, aiming to allow wide and complex body reshapings. Acellular dermal matrices are one of these devices, and are made of human or animal tissues made acellular after their sampling. They are used for cervical, breast and abdominal wall reconstruction. Tutopatch, generally used for face reconstruction or neurosurgery, is made of acellular bovine pericardium, and its high amount of collagen allows a fast tissue healing and a scaffold for the surrounding tissue regeneration. In our case report Tutopatch has been used in immediate breast reconstruction after mastectomy. This device has been used to close laterally the subpectoral pocket, allowing a bigger volume prosthesis to be placed We have not experienced particular postoperatory complications, and after 12 months of follow up we have found a valid functional and aesthetic result. We consider Tutopatch as a valid alternative to other acellular dermal matrices specifically designed for breast reconstruction

Oncoplastic surgery and cancer relapses : cosmetic and oncological results in 489 patients

During the past 20 years, breast conservation has become the preferred treatment modality for breast carcinoma, and in recent times there is an increased expectation from breast cancer patients to retain their "normal breast appearance". For large tumor-to-breast ratio excision, the subspecialty of oncoplastic surgery is born, helping to achieve a good oncologic and esthetic result. In our study we have considered 767 patients undergone a mastectomy or quadrantectomy, and especially 489 undergone quadrantectomy. We have used our protocol for breast reshaping and analyzed our data in terms of oncologic safety and esthetic results. Considering the lesions, they were placed like this: 214 (44%) in the SEQ, 58 lesions (12%) in the SIQ, 54 lesions (11%) in the IEQ, 24 lesions (5%) in the IIQ, 45 lesions (9%) respectively in the CQ and between the SQ, 39 lesions (8%) between the EQ, 5 lesions (1%) respectively between the internal quadrants and between the inferior quadrants. We have chosen simple breast reshapings in case of operations on the superior quadrants, while, in case of operations on the inferior quadrants, we have chosen complex techniques, like reshapings according to a "key hole" reductive mammaplasty, which requires also a contralateral reshaping. We have done simple and monolateral reshapings respectively in 372 (76%) and 296 (60.5%) cases. We have had early complications in 98 (20%) cases: 12 infections (2.4%), 10 hematomas (2%), 11 seromas (2.2%), 65 liponecrosis. As late complications, we have found scar retractions and minus areas in 20 cases (4.08%), while we have found asymmetries and bigger deformities in 34 cases (6.95%). We have not found any cancer relapse after one year of follow up, while we have had 3 cases of relapse (0.6%) after 5 years of follow up, respectively after 5, 4 and 2 years. This result has to be attributed to our preoperatory project of surgery derived from many factors, among which stands out the MRI done in all the cases. We think that an immediate breast reshaping following quadrantectomy is the best esthetic and psychologic option for breast cancer patients

Impact of intraoperative radiotherapy on cosmetic outcome and complications after oncoplastic breast surgery

Breast cancer is one of the most common tumors in the population worldwide. Conservative breast surgery (CBS) is one of the preferred surgical options, because both the oncologic and esthetic needs of the patient can be addressed. CBS surgical outcomes tend to be more effective with reduced chances of disease recurrence when radiotherapy (RT) treatment is considered as an adjunct treatment, either applied during surgery (IORT) and/or after (EBRT). The purpose of our study was to compare surgical outcomes between IORT and EBRT after CBS. In the past 5 years, we performed CBS in 489 patients in our clinic. Of these patients, 83 underwent adjunct treatment with IORT and 109 were treated with EBRT in accordance with our university approved clinical protocol. Surgical outcomes, early complication rates, and esthetic results were compared between these two groups of CBS patients, with a mean follow-up time of 17 months. IORT allowed breast irradiation treatment to be performed without effecting overlying skin, thus cosmetic outcomes tended to be favorable. Esthetic postoperative results assessed with the Breast Cancer Conservation Treatment (BCCTcore) software showed that the differences between IORT and EBRT were not statistically significant (including those patients that underwent further oncoplastic techniques after EBRT). The disease recurrence rates between the two groups were not significantly different. IORT is a safe, fast, and feasible technique that provides effective and comparable CBS outcomes for patients with breast cancer

Association of Brain Atrophy With Disease Progression Independent of Relapse Activity in Patients With Relapsing Multiple Sclerosis.

The mechanisms driving neurodegeneration and brain atrophy in relapsing multiple sclerosis (RMS) are not completely understood. To determine whether disability progression independent of relapse activity (PIRA) in patients with RMS is associated with accelerated brain tissue loss. In this observational, longitudinal cohort study with median (IQR) follow-up of 3.2 years (2.0-4.9), data were acquired from January 2012 to September 2019 in a consortium of tertiary university and nonuniversity referral hospitals. Patients were included if they had regular clinical follow-up and at least 2 brain magnetic resonance imaging (MRI) scans suitable for volumetric analysis. Data were analyzed between January 2020 and March 2021. According to the clinical evolution during the entire observation, patients were classified as those presenting (1) relapse activity only, (2) PIRA episodes only, (3) mixed activity, or (4) clinical stability. Mean difference in annual percentage change (MD-APC) in brain volume/cortical thickness between groups, calculated after propensity score matching. Brain atrophy rates, and their association with the variables of interest, were explored with linear mixed-effect models. Included were 1904 brain MRI scans from 516 patients with RMS (67.4% female; mean [SD] age, 41.4 [11.1] years; median [IQR] Expanded Disability Status Scale score, 2.0 [1.5-3.0]). Scans with insufficient quality were excluded (n = 19). Radiological inflammatory activity was associated with increased atrophy rates in several brain compartments, while an increased annualized relapse rate was linked to accelerated deep gray matter (GM) volume loss. When compared with clinically stable patients, patients with PIRA had an increased rate of brain volume loss (MD-APC, -0.36; 95% CI, -0.60 to -0.12; P = .02), mainly driven by GM loss in the cerebral cortex. Patients who were relapsing presented increased whole brain atrophy (MD-APC, -0.18; 95% CI, -0.34 to -0.02; P = .04) with respect to clinically stable patients, with accelerated GM loss in both cerebral cortex and deep GM. No differences in brain atrophy rates were measured between patients with PIRA and those presenting relapse activity. Our study shows that patients with RMS and PIRA exhibit accelerated brain atrophy, especially in the cerebral cortex. These results point to the need to recognize the insidious manifestations of PIRA in clinical practice and to further evaluate treatment strategies for patients with PIRA in clinical trials